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<meta name="description" content="两周前在朋友圈看到王海鹏老师贴面班课程的信息，正好之前几个月我做过两例前牙贴面的病例，有一些问题。我有同事参加过王老师的班，说不错。尽管学费不便宜(6000)，又是在北京，还是报了名。6月11日到13日学了三天，收获不小。王老师讲得真好，我对做贴面比以前有信心了。更重要的是，王老师课程里的一些观念，一些原则性的内容，我觉得不光做贴面有用，全冠，嵌体等修复，甚至口腔其它领域，都有用。现在是6月14日">
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        <p>两周前在朋友圈看到王海鹏老师贴面班课程的信息，正好之前几个月我做过两例前牙贴面的病例，有一些问题。我有同事参加过王老师的班，说不错。尽管学费不便宜(6000)，又是在北京，还是报了名。<br>6月11日到13日学了三天，收获不小。王老师讲得真好，我对做贴面比以前有信心了。更重要的是，王老师课程里的一些观念，一些原则性的内容，我觉得不光做贴面有用，全冠，嵌体等修复，甚至口腔其它领域，都有用。<br>现在是6月14日凌晨三点半，我在天安门广场排队看升旗，就写一下总结吧。这次学习我不像以前那样啪啪啪用手机拍照了，一方面是讲义都印出来发给每位学员了，二是我想换个方式，自己总结一下，所谓的费曼技巧吧。<br>首先是”技”的方面，如何备一个贴面？第一步不是谈好价钱让患者躺牙椅上开始踩机器磨牙，而是做美学分析，看该不该做，用不用磨牙，磨多少。这里面最关键的，一是拍照，二是做诊断蜡型。<br>这些都做完以后，就要制作硅橡胶背板，把硅橡胶重体调好放到做好的蜡型上，硬固以后取下来就行。这涉及到硅橡胶的材料特性的问题:硅橡胶聚合分三个期:工作期，聚合期，稳定期。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/01.jpg"><br>在工作期才能操作，到了聚合期就不能再施压了，不然印模会变形。硅胶背板的厚度不能少于3MM，另外也应该覆盖龈缘以下3-5MM。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/02.jpg"><br>完了就进行下一步，mock-up。也就是利用硅胶背板和临时冠材料把诊断蜡型的设计翻到患者口内。目的有几个，一是医患沟通，二是用mock-up指导牙体预备。<br>这个并没有实操，放一个我自己以前做的吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/03.jpg"><br>自己感觉，做这个对成交蛮有帮助的。<br>mock-up满意以后，就可以开始牙体预备了，注意是在mock-up上备牙，这样如果没有磨到牙齿，就说明这个地方是不需要预备的。<br>在进行预备以前，还有个要进行的操作是记录咬合，用咬合纸咬，然后拍照。在戴牙以后要恢复同样的咬合。<br>接着是牙体预备的具体原则:<br>坚持五查:体位(医生的)，头向(患者的)，切线(医生的视线应该与要预备的牙面相切，这样看得最清楚)，轴向(即车针的方向，一旦确定了，在预备过程中就不能随意改变，要锁定轴向，平行移动。控制了轴向就控制了车针)，比例(即磨除量，要点是用车针当尺子，这就涉及到要了解自己用的车针的尺寸了)。<br>另外一个关键的要点是备牙的时候不能施力，用车针旋转的力量磨除就足够了。车针要在牙体上顺滑的运动，而不是刻意的用手指去压手机。具体标准就是脱了手套备牙的时候指甲不会发白。<br>每一个预备步骤每一针都要进行五查，没有做到就不要踩踏板，没有达到标准就不要进入下一步。<br>预备时尽量用拉的动作别用推的动作。<br>下面就是牙体预备的具体步骤了。<br>用的车针是这些<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/04.jpg"><br>①唇面定深<br>定深0.3MM。<br>体位:9点位。<br>头向:远离医生。<br>切线:实线与远中边缘嵴相切，即从九点位看过去能看到牙的唇面平面。<br>轴向:车针轴与牙体长轴平行。<br>比例:车针没入牙体，直到车针柄与牙体接触。<br>从远中往近中拉，尽量一次完成，不然沟的宽度会过长。一般定三条沟。用铅笔将定深沟涂黑。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/05.jpg"><br>②磨除定深<br>用鱼雷状的车针磨除定深，但是保留涂黑的沟底。<br>体位，头向，切线都和第一步相同。轴向分三个区域，都与牙体表面平行。比例，磨除定深但保留沟底。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/06.jpg"><br>③邻面边缘线的确定<br>这个我觉得是难点，另外就是磨了但是看不出来，可能取了模才看出来。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/07.jpg"><br>最好预备成狗腿形的，就是在切端靠近唇侧，在龈端将车针伸入腭侧，形成一个角度，这样能使贴面覆盖邻面，不容易引起邻面暴露或者贴面折裂。<br>还是用鱼雷车针。<br>体位:12点位<br>头向:正中位<br>切线:邻面与医生相切，对着自己的扣子。<br>轴向:首先在切端垂直于邻面，然后稍偏牙体(3°)，运动到邻接区接触点后，车针竖起，并逐渐伸入到腭方。<br>比例:车针没入一半，不要损伤邻牙。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/08.jpg"><br>④唇侧肩台的预备。<br>用圆头柱状车针。<br>体位，头向都同前。<br>切线向正中<br>车针轴向先紧贴牙面，然后竖起，仅尖端0.5-1.0MM与牙体接触(可以用口镜在3点钟位观察)。<br>比例:车针没入一半，形成0.3MM的肩台。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/09.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/10.jpg"><br>⑤平滑邻面与唇侧颈部肩台<br>体位:12点位。<br>头向:稍偏。<br>切线:与邻面边缘末端和颈部肩台起点的连线相切。<br>轴向:垂直于该连线，在牙体上轻滑。<br>比例:同颈部肩台。<br>⑥用黄标车针，抛光。<br>钨钢车针慢速时抛光性能是最好的。<br>完了就到排龈，取模阶段了，就不赘述了。原则是接近牙龈的操作就要排龈(包括前面备唇侧肩台时，正确排龈后离排龈线0.3MM预备，就不会侵犯生物学宽度啦)，用硅橡胶取模，二次法，用钢托盘(凡是你掰得动的托盘都别用)，注意操作期以后就别动也别施压了。取模前要填倒凹，别自己灌模。印模应该有360°连续的边缘线。<br>咬合记录要用硬的硅胶取。<br>用背板制作临时修复体，仔细抛光，点状酸蚀后用树脂粘接。标准是来戴牙时牙龈无损伤。<br>进行美学修复要有好的技师的支持。<br>接下来就是戴牙了，修复体来了要在模型上检查修复体，合格了再约患者。用探针在戴了修复体的代型上检测修复体边缘，要没有悬突(水平向间隙)，垂直向间隙小于30μm。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/11.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/12.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/13.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/14.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/15.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/16.jpg"><br>然后就是戴牙了。是否使用橡皮障，看患牙情况，不伤牙龈为原则。具体操作根据使用的产品的说明书来，别老自创。氢氟酸emax处理20s，烤瓷贴面建议60s。硅烷偶联剂处理5分钟以上，或用热吹风机处理30秒。<br>戴完贴面，要仔细去除多余粘接剂，最好在显微镜或放大镜下操作。<br>最后，仔细抛光。尤其是不备牙贴面。<br>以上就是我这次学习的简单总结，还有很多内容，比如美学分析，只是简单讲了一下，其实美学分析才是最关键的。自己看书吧。技术决定下限，审美决定上限。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/17.jpg"><br>升旗了，祝民富国强。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0141-whptm/18.jpg"></p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“好看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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